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An 87 y/o female with hx of CAD complains of chest pain and dyspnea on exertion.

Q1. What does the EKG demonstrate?

A1. This EKG has several abnormal findings:

This is a sinus rhythm, however the PR interval is 0.24 seconds. This is diagnostic of a 1st degree AV block.

Every 4th beat is a PVC. (On the rhythm strip, beats #2, 6, 10, and 14 are PVCs). This is called ventricular quadrigeminy. PVCs come earlier than the next expected beat (premature) and the QRS complex is wide and different than the native beats.

The QRS complex is 0.10 seconds wide with RSR’ in V6, I, aVL and a left axis deviation. This is diagnostic of a left intraventricular conduction delay (IVCD). A left IVCD is like a “baby” left bundle branch block. The QRS is wider than normal, but not wide enough to diagnose a left bundle branch block (> 0.12 seconds).

There are ST depressions in leads V3-V6, I, aVL. There are no ST elevations. This is suggestive of lateral wall ischemia.

The QT is prolonged.

In our patient with chest pain and DOE, the lateral ST depressions are concerning for new ischemia. She should be evaluated and treated for an acute coronary syndrome. 1st degree AV block is usually benign and usually does not require any specific treatment. Quadrigeminal PVCs are usually stable, are very unlikely to degenerate into V-tach, and usually require no treatment. QT prolongation is concerning in the setting of syncope, palpitations, or toxic ingestions. In patients with QT prolongation, drugs which prolong the QT should be avoided.